Application — The Children's Refuge

Application Phase 1

To nominate a child for the outdoor experience, please fill out the form and click submit. A representative will be in touch once the application is complete.

For additional information, please contact us at 281-477-6544.

Name *

Name

First Name

Last Name

Email Address *

Comments *

Child Name

Child Name

First Name

Last Name

Child Age

Date Of Birth *

Child Nickname

Physician Name

Physician Name

First Name

Last Name

Physician Address

Physician Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physician Phone

Physician Phone

(###)

###

####

Physician Contact

May we contact your family physician?

Parent/Guardian 1 Info

Mother

Father

Legal Guardian

Parent/Guardian 1 Name

Parent/Guardian 1 Name

First Name

Last Name

Parent/Guardian 1 Primary Phone

Parent/Guardian 1 Primary Phone

(###)

###

####

Parent/Guardian 1 Cell Phone

Parent/Guardian 1 Cell Phone

(###)

###

####

Parent/Guardian 1 Address

Parent/Guardian 1 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 1 Email

Parent/Guardian 2 Info

Father

Mother

Legal Guardian

Parent/Guardian 2 Name

Parent/Guardian 2 Name

First Name

Last Name

Parent/Guardian 2 Work Phone

Parent/Guardian 2 Work Phone

(###)

###

####

Parent/Guardian 2 Cell Phone

Parent/Guardian 2 Cell Phone

(###)

###

####

Parent/Guardian 2 Address

Parent/Guardian 2 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 2 Email

Parent/Guardian 3 Info

Father

Mother

Legal Guardian

Parent/Guardian 3 Name

Parent/Guardian 3 Name

First Name

Last Name

Parent/Guardian 3 Work Phone

Parent/Guardian 3 Work Phone

(###)

###

####

Parent/Guardian 3 Cell Phone

Parent/Guardian 3 Cell Phone

(###)

###

####

Parent/Guardian 3 Address

Parent/Guardian 3 Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 3 Email

Sibling Info

Names and ages of sibling(s) living in the same household.

Parental Info

If parents divorced or separated, please list the parent the child lives with.

Father

Mother

Legal Custody

Does the parent have legal custody?

Yes

No

Legal Custody Info

If the child is not in legal custody of either parent, please explain the relationship of the guardian.

Race

Please share information about the race of the student.

Caucasian

African American

Hispanic

Asian

Other

Active Military

Is the child an active duty military dependent?

Yes

No

Active Military Info

If yes, which branch of service?

Physical Info

Does the child have any physical limitations that must be accommodated during an outdoor adventure?

Outdoor Adventure Info

Has the child ever had an outdoor wish granted?

Yes

No

Applied, but not received

Hunter Safety Course

Has the child completed a hunter safety course?

Yes

No

Hunter Safety Info

If yes, please list state issued and certificate number of hunter safety course.

How Did You Hear About The Children's Refuge?

Please share how you heard about us.

Is your child undergoing regular treatments?

If yes, please explain.

Approval Info

If approved, will the child and family be able to travel within 90 days? If the answer is "no", please explain:

Social Worker Info

Does the child have a Social Worker or Child Life Specialist? If so, please provide Name, Address, Phone and Email:

Waiver Of Liability

If the child is approved for the The Children's Refuge Outdoor Adventure, a parent or guardian will be required to sign a Waiver of Liability (Check box if you understand a waiver is required)?

Yes

No

Photo/Video Release

I give permission for photographs and video of my child to be shared on social media, promotions, or public use on websites and printed materials.

Yes

No

I am

Please share your relationship to the child.

Child's Parent

Child's Guardian

Friend

Family Member

Other